Graded Activity and Graded Exposure for Persistent Nonspecific Low Back Pain: A Systematic Review

• Published in: Physical therapy 2010-06, Vol.90 (6), p.860-879
• Main Authors: Macedo, Luciana G, Smeets, Rob J E M, Maher, Christopher G, Latimer, Jane, McAuley, James H
• Format: Article
• Language: English
• Subjects: Anxiety; Behavior; Care and treatment; Classical conditioning; Clinical trials; Cognitive therapy; Conditioning (Psychology); Data collection; Evaluation; Exercise Therapy - methods; Humans; Intervention; Low back pain; Low Back Pain - rehabilitation; Methods; Outcome and Process Assessment (Health Care); Patient outcomes; Physical therapy; Physical Therapy Modalities; Randomized Controlled Trials as Topic; Studies; Therapeutics, Physiological
• ISSN: 0031-9023; 1538-6724
• DOI: 10.2522/ptj.20090303

Graded activity and graded exposure are increasingly being used in the management of persistent low back pain; however, their effectiveness remains poorly understood. The aim of this study was to systematically review randomized controlled trials that evaluated the effectiveness of graded activity or graded exposure for persistent (>6 weeks in duration or recurrent) low back pain. Trials were electronically searched and rated for quality by use of the PEDro scale (values of 0-10). Randomized controlled trials of graded activity or graded exposure that included pain, disability, global perceived effect, or work status outcomes were included in the study. Outcomes were converted to a scale from 0 to 100. Trials were pooled with software used for preparing and maintaining Cochrane reviews. are presented as weighted mean differences with 95% confidence intervals. Fifteen trials with 1,654 patients were included. The trials had a median quality score of 6 (range=3-9). Pooled effects from 6 trials comparing graded activity with a minimal intervention or no treatment favored graded activity, with 4 contrasts being statistically significant: mean values (95% confidence intervals) for pain in the short term, pain in the intermediate term, disability in the short term, and disability in the intermediate term were -6.2 (-9.4 to -3.0), -5.5 (-9.9 to -1.0), -6.5 (-10.1 to -3.0), and -3.9 (-7.4 to -0.4), respectively. None of the pooled effects from 6 trials comparing graded activity with another form of exercise, from 4 trials comparing graded activity with graded exposure, and from 2 trials comparing graded exposure with a waiting list were statistically significant. Limitations of this review include the low quality of the studies, primarily those that evaluated graded exposure; the use of various types of outome measures; and differences in the implementation of the interventions, adding to the heterogeneity of the studies. The available evidence suggests that graded activity in the short term and intermediate term is slightly more effective than a minimal intervention but not more effective than other forms of exercise for persistent low back pain. The limited evidence suggests that graded exposure is as effective as minimal treatment or graded activity for persistent low back pain.